HomeMy WebLinkAboutAMBER LT 9AAmber
Lot 9A
#050-273-27
Rick Mystrom,
Mayor
umc panry of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
November 6, 1997
Shawn A Floria
17031 Foothill Avenue
Eagle River, Alaska 99577 8146
Subject: Lot 9A Ain~er Subdivision
Permit #SW960353, PID #050-273-27
The subject permit, issued October 22, 1996 by this office for a
single family well and/or on-site wastewater system, has
expired as of October 22, 1997.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well log must be sent to
this office for documentation of the installation and to
close the permit.
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as-built inspection report must be sent to this office for
review, approval and documentation. All inspection reports
must be submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a Combined on-site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
~erely, ~
On-site Services
enc: Copy of Permit
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF }{EALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE
1 OF
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW960353
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:FLORIO SHAWN A
OWNER ADDRESS:17031 FOOTHILL AVE.
EAGLE RIVER, AK 99577
DATE ISSUED:10/22/96
EXPIRATION DATE:10/22/97
PARCEL ID:05027327
LEGAL DESCRIPTION:
AMBER LT 9A
LOT SIZE: 46445 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT:
3
THIS PERMIT IS FOR THE CONSTRUCTION OF:'
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
THE EXISTING WELL MOST BE ABANDONED IN ACCORDANCE WITH
AMC 15.55.I.1.
A WELL LOG AND AS-BUILT DRAWING MUST BE SUBMITTED TO THE
.LLo
DATE:
DATE:
QGRE
ANCHORAGE AREA B0F
Department of Environmental Quality
3330 C Street
Anchorage, Alaska g9503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
CAT,ON" ,~'~ LEGAL
SEPTIC TANK:
NUMBER OF
COMPARTMENTS
INSIDE LENGTH
INSIDE WIDTH
LIQUID DEPTH
LIQUID CAPACITY/~-) ~)~--'2 GALLONS.
SEEPAGE PIT:
NUMBER OF PITS ~ DIAMETER OR WIDTH ~J%, LENGTH____~, DEPTH
LINING MATERIAL/'~O~--ff-~ CRIB SIZE: DIAMETER__DEPTH DISTANCE FROM: WELL /
BUILDING FOUNDATION/z~)' NEAREST LOT LINE qO' TOTAL EFFECTIVE
, ABSORPTION AREA (WALL AREA) Z~-~L SQ. FT.
ADDITIONAL ABSORPTION
WELL:
BUILDING Z!
FOUNDATION __
CESSPOOL
APPROVED
NEAREST
LOT LINE
DEPTH ~'/ t
DISTANCE FROM:
NEAREST SEPTIC SEEPAGE /~.~
SEWER LINE ., TANK /~:::;~2 SYSTEM
, OTHER SOURCES
DISAPPROVED REMARKS
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY: /~2/~ ~
PiPe MATERIAL' ~// C°--~/'' ;/'~)~
LOT SLOPE:
Form No. EO-031
GreaTer ANCHORAGE ArEA Borough
DEPARTMENT O~ ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-4561
NAME OF APPLICANT
INSTALLATION LOCATION. ~-'~'~''/-~
INSTALLATION Of: SEPTIC TANK ... ~. SEEPAGE PIT/~
TYP' AND ~'ZE OF FAC'L~TY TO BE ~ERVED ~ ~ ~~ I
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
!
FINANCED THROUGH
PERMIT NO.
TO BE INSTALLED BY
PHONE
, DRAIN fieLD
OTHER
SOIL TEST RESULTS
NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE /~) TYPE
SEEPAGE AREA SIZE
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
SEPTIC TAN~ TO SEEPAGE P~T WALL
SEPTIC TANK , SEEPAGE PIT : DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD
ALSO CONSIDER AREA WELLS.
DIAGRAM OF SYSTEM
WATER MAIN TO SEPTIC TANK
DRAIN FIELD --.
la'
SEPTIC TANK, , SEEPAGE PIT
TO RiVEr, LAKE, STREAM.
SEEPAGE Pit
DRAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EX~CAVATION 5 FEET INTO UNDISTURBED SOIL.
~__4_JJ:~14~: ~:.~.,~.~,E~EJL_C~AST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT rEMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESC RI B ED~YSTEM/fl~ IN ACCORDANCE W,TH SAID CODE.
Parcel I.D. #
050-273-27
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental SerVices r
~' On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA# HAq t05 B
1. GENERAL INFORMATION
Complete legal description
Amber Lot 9A
Location (site address or directions)'
17031 Foothill Drive, Eagle River
Property owner William & Kathleen Wyrick Day phone
Mailing address HCR 83 Box 214. Eagle River, AK 99577
694-8171
Lending agency
Day phone
Mailing address
Agent
Address
Re/Max of Eagle River, Linda Banner
Day phone
16600 Centerfield Drive, Eagle River, AK 99577
694-4200
Unless otherwise requested; HAA will be held for pickup.
2. NUMBER OF BEDROOMS: .... 3
3. TYPE OF WATER SUPPLY:
NOTE:
Individual well
Community well
Public water
4. TYPE OF WASTEWATER DISPOSAL:
x
If community well system, provide written confirmation from State"ADEC attest- '
lng to the legality and status of system.
Individual on-site
Holding tank
x
Community on-site
NOTE:
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA#21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my Seal affiXed heret~3 and as' of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my inves_ti_gation and inspection, the on-site water
supply and/or wastewatef disp0sal SYStem is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Eagle 'River Engineering Services Phone
Address P.O. Box 773294, Eagle River, AK 99577
Engineer's signature
Approved for ~ ~
Disapproved.
Conditional approval for
bedrooms.
DHHS SIGNATURE
694-5195
Date /~ - a ,/- ~'~,
bedrooms, with the following stipulations:
Date //'44'~'/
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
?2-O25(Rev. 1/91) Back MOA~%~21' ~ ~
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~/~£/~ LO?' ~
Parcel I.D.
A. Well Data
Well type /P£/~,'~?'Z; If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ~ Date completed ~?/~ ~/?~ Driller
Total depth ~/' ~P~ /0/?~ Cased to ~ ~' Casing height
Sanitary seal (Y/N) YE~ Wires properly protected (Y/N)
FROM WELL LOG
Date of test ,.--"J
Static water level
Well flow
Pump level1 /
SEPARATION DISTANCES FROM WELL TO:
Septic/l:~t~ng tank on lot
Absorption field on lot
Public sewer main
~- joo ~
Sewer service line
AT INSPECTION
g.p.m. /' ~' g.p.m.
; On adjacent lots -/"/0~) /
; On adjacent lots -~/00 '
Public sewer manhole/cleanout /~///~
!-!'1
.-_{
Petroleum tank /w,¥~ ~/,~,,~.,~,,~/,.~-
WATER SAMPLE RESULTS:
Coliform ~
Date of sample:
Nitrate
5/ /~/(~//--- Other bacteria '~
Collected by:
B. SEPTIC/I~I~G TANK DATA
Date installed ID~ '~ .~
Cleanouts (Y/N) .)/zE ~
High water alarm (Y/N)
Date of pumping
Tank size /~0 Compartments
Foundation cleanout (Y/N) ,,~ Depression (Y/N)
/F'//~ Alarm tested (Y/N)
: ~'/$0//0/"/ Pumper
SEPARATION DISTANCES FROM SEPTIC/I-I~L=~ING TANK TO:
Well(s) on lot +/o~ ~
To property line _4-¢,
Surface water/drainage
On adjacent lots
Absorption field
Foundation
Water ma~/service line y~,z~"
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
Manufacturer ~
Manhole/A~
~- "Pump off" Level at
~~gcles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length / ¢'
Total absorption area
Date of adequacy test
Water level in absorption field before test /-//, 7~-
Peroxide treatment (past 12 months) (Y/N)
Width
Soil rating (GPD/FF)
./~ ' Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
/9 ~ ~,:r.,..,~.System type /P/7-
~-~ ~ Total depth
Depression over field (Y/N)
~ for
After test ~
If yes, give date
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /.2o ~
To building foundation
On adjacent lots C-
Surface water ,~/,4
On adjacent lots '/'/~ / Property line /? /
To existing or abandoned system on lot /~//"¢
Cutbank ,¢//~ Water ma~/service line //z '
Driveway, parking/vehicle storage area -¢¢' '
Curtain drain ,'~',,/~
E. ENGINEER'S CERTIFICATION
I certify that l have checked, verified, or conformed to all MOA and HAA guideline~ in eCe~?~ tt~e':~a~e;!~¢!!hi¢,inspection.
Signature ~
....
Engineer's Name
Date ,/~ -- ~
HAAFee$ ~0~
Date of Payment
Receipt Number '-/
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93) Back
11~24/94
C'PAE ENIJI~TI:~_ LAB E~cR~IICES
Commercial Testing & Engineering Co.
Environmental Laboratoo/Sewices
94. ~ ~9 -]
WATER
LABORATORY ANALYSIS REPORT
EAGL~ ~ZVgA ~I/~RING
~A
WORK O~de= 10214
PriCed D~Ce 10/24/94 ~ 05:~8 hrs.
Co~lecCe~ D~c~ XO/~9/gA ~ ~1~27 hrs.
R~ce£ve~ D~& ~0/19/9A ~ 16:00 hrs.
"-~&~l~ Ee~arks: ROUTIN~ SAMPL~ cOLL~u-£~ BY: M.J.N.
QC Allow&ble l!bcC. Anal
6.51 ~/~, EPA 353,~/300.0 1o 10/21/94 MCE
Re~rte~ val~ is che ~racCic~l ~nti~icaCio~ li~. LT - ~s.
OT - G~ea=er
diluci~.
6633 B Strut, Ane~e, AK 99518-1~- Tel: [~7} 562-2343 Fax: (~7)561.6301
ENVIRONMENTAL FACILITIES IN ALASKA. COLOgADO, FLORIDA, ILUNOI~. MARYt. ANO. NEW JERSEY, OHIO. UTAH, WE~r VIRGINIA
CT~E E-NUIRDNHENT61_ LAB ~ICE$ - gO7 694
COMMERCIAL TESTING & ENGh,EERING CO. AK DIV
....q.~.I~I~...M..,..!CAJ_,, & GEO~ LOGICAL I~. . ORATOI~Y
'"" TEI. EPI'ICSq~ (~1662.'~a43 ~ e
';:; .
Otinking .Wator Aaalysis ~eport ~or Total Coliform Bactsria
TO BE COMPLETED BY WATER SUPPLIER '
D PU~UC WATEll SYSTEM I.O,.'#~
[] PRIVATE WATER SYSTEM
) [] Treated Water
Z;~tmated Watar
SAMPLE TYP E:
CI Cher,~ Sample (for mmlne aampl.
with lab ref. no.
TO BE COMPLETED BY LABORATORY
.t
y~tis sh~ws this Waler SAMPLE ~o 13e:
[sfac~o~/
[] u~atlsfacmr/
FI Samp~ lo~ Iotlg itt transit; saltine should
r~t be ovgr 30 hours old at examination
to Indicaie reiiabte results. Please se~d
new sample via sper~l delivow mail.
* No, ot colonies/1 O0 mt.
I.~b Ref. !~. Reaalt*
I ] r-tn
Analyst
BACTERIOLOGICAL WA'IT:FI ANALYJ~,.~ RECORD
,~d~MPLE 'llme Cotlaeted
No. LOCATION
READ INSTRUCTIONS~ ,..~..,, e,~-. m,,-a.~u,~ ¢'J ~'~ -~
B~ORE '
,. :' . :.::,:,:c...-*"' :~,~."-..~', ~~~'":"""~ .... '"'~'~ ..... : ~"'" ...... "*'~"'
COLLEC~NG SAM~~ ~l ~ R~ "~ ~. ~ . ~~ m~
Re~
T~C ~ Too Numemu~ To Count
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date '-~ -/~-- ~ ~
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name /~¢17,~ X. ~/~, Telephone: Home Business
Applicant Address ' ,/~-~,, ~,
(c) A, pplicant is (check one}: Lending Institution []; Owner/builder []; Buyer []; Other~ (explain);
(d) Lending Institution' Telephone
Address '
(e) Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
SRB 196x
TYPE OF RESIDENCE
Singte-Family/~ Multi-Family []
Number of Bedrooms ~-
Other
WATER SUPPLY
Individual Well)~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite')!~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm S & S Eng1~em'|n§
SI~B
Address ~ _j~-.
Date
Telephone
DHEP APPROVAL ~...~.~ ..~-.
Approved for'--'~C~': b~ eOrooms b .... te ~-- ~' ~ ~ ~
Approved ,~Q~ DiSapproved Gonditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work. ..
Page 2 of 2
72-025 (11/84)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MO,.,~
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Well Classification ~
Well Log Present,(,~ Date Completed
Cased to ~O '/'
Total Depth
Static Water Level
Casing Height Above Ground
Electri..caI.Wiring in Conduiti~N~
Separation iDistances from Well:
To Septic/Holding Tank on. Lot"
Legal Description:
MUNJCIPALIT~ OF ANCHORAGE
DEPT. OF HEALTH &
ENVIROflI~EHTN' PROTECTION
If A, B, C, D.E.C. Approved (Y/N)
To Nearest Edge of Absorption Field on LDt
To Nearest Public Sewer Line ~"~/A-
.- Cl~anout/Manhole ~
Water :Sample C°llectred by.
Water SampleTest Results'
Comments
/ ~r/'/3 Yield
Depth of Grouting
Pump Set At
SAnitary Seal on Casing~/'l~
Depression Around Wellhead,(,,Y'~
; On Adjoining Lots
/,~ ~r ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed / q ~'~3 Size a/'~ O ~ No. of Compartments '~'
Standpipe~J~ Air-tight Caps ~ Foundation Cleanout ~
Depression over Tank ~ Date Last Pumped ._~'" / ~:~'" '~ ~'
Pumping/Maintenance Contract on File (Y/N) ~.~./~. '"~/A ;for '--'
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~4:~&3 t ~-
TO Property Line /~) * ~''
To Water ........ Serwce Line
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed //~ '~ ~'
Width of Field /,,~ t
Square Feet of Absorption Area
Depression over Field
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot /~'/,~
To Water Mcin/Service Line
~~_ Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Presenti~J~'
Date of Last Adequacy Test
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line
· On Adjoining Lots
To Cutbank (if present)
To Existing or Abandoned System on
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
bj//"Pump Off" Level at
Vent (Y/N)
/ ~ Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed JI 4, ,~ ,.Srl. m~ln.~. Date
MOA No. ,'~b"-~d;~ 5
Page 2 of 2
72-026 (11/84)
CHEMICAL & G,_.OLOGICAL LABORATORIES ,..F ALASKA, INC.
TELEPHONE (907) 562-2343
5633 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
[] PUBLIC WATER SYSTEM I.D.#
~-PRIVATE WATER SYSTEM
Name
Phone No.
City State
Mo. Day Year
Zip Code
SAMPLE TYPE:
.E~Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
) [] Treated Water
~ Untreated Water
SAMPLE
NO. LOCATION
2 I
3 I
4 I
5 I
Time Collected
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
tisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
Analyst
Lab Ref. No. Result*
I ~
I ~-~
I
I F-r-1
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Fil~~
Reported By v - ~
TNTC = Too Numberous To Count
OB -' Other Bacteria
BGB
Collformll00ml
Collformll00ml
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF ~F.~LTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR ~tt~.ALTH AUTHORITY APPROVAL CERTIFICATE
:~: 1. ~eneral Information
(a) Legal_Desc.ription_(inclRde loth block, subdiviston,~section, township, range)
.. ? ,._,
, Telephone - Home
Applicants Addre~ss
(c) Applic~ant is (check o~) Lending Inst~ution ~ ; Owner/builder ~--~ ;
(d) Lending Institution //~ /.3 ~ Telephone
Application Date
Bus ines s
Address
/---~ 7 ~ '" -'"..
Address ~(~, /:~'9/'' '~ ~ :~ ~-~~~.~ ~ ,
Telephone ~q~-
(f) ~ the ~ to the follo~n~
2. T~pe of Residence
Single-Family~
Number of Bedrooms
3. Water Supply
Individual
Multi-Family ~ Other (describe)
Communizy~-~ Public~--~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite ~ Public ~-~ Community ~ Eolding Tank i i
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2] ~
Firm Providing. ,Inspections ~ Testst File Searcht Data and Informatiou
DHEP Approval
Approved for ~~bedrooms
Approved ..~ Disapproved
Terms of Conditional Approval
certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of. this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure iv~icated herein.. I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the' on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm ~ ................ Telephone
SRB 198X
Conditional
CAUTION
TH~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMEN~fAL PROTECTION
(DEEP) ISSUES H~LTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN P.~RAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DEEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL _AND STATE REQULRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLg FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/eJ/D18
[Page 2 of 2]
7 -19-84
Well Classification .~I~W'~/~ ~
Well Log Pmesent (~)~
Total Depth. ~--/ '"/ Cased to
Static Water Level ~-- !
Casing Height Above Ground / 2. ;t
Electrical Wiring in Conduit ~
Separation Distances f=cm Well:
To Septic/HoldiD~] Tank on Lot .... ~/..~,0 ,. £~
MUNICIPALITY OF ANCHORAGE
D~:PT. OF HEALTH &
ENVI MENTAL PROTECTION
~c~P~ oF ~C~G~.
198~
Legal Description: ~ ~
If A, B, (~ 0, D.~..C. App~oved(.Y./N.) ~ .~,
z-'/O "'/- Depth of (k,'outing ~ /' ,
Pump SetAt ~ ~'
7~ Sanitary Seal on Casing~/~.)
Depmession A~ound Wellhead (~/~),/
To Nearest Edge of AbscFption Field on Lot /~O (
To Nearest Public Sewer Line /%/ ///~ To Nearest Public Sewer
Cleancut/Manhole /%/~/, _/~ To Nea~.est Sewer Service Line. on Lot
Water Sample Collected By._~..?--~ ~/~~.///~ Date....~//.~/~3~
Water Sample Test Bssults ~ ~ ~/c ~ C ~3
Ccaw~ents .... ~ AJ~. ,
; On Adjoining Lots /6)0
~ On Adjoining Lots /OO
SEPTIC/HOLDING TANK DATA
Standpipes~Y~) 'r- 'gh Dsl~/~, O t'onCleanout (~N~ '
Depmession over Tank (,~ Date Las~{~m~ped
Pumping/Maintenance Con=a= on File ('~,)~ ; for
.
Holding Tank High-Water Alarm (Y/N~//~g- Temporaz7 Holding Tank Permit
Separation Distances f=cm____SePtic/~]~]~/. Tank:
To Property Line /6~. , ''~ To Disposal Field , 2 ~- /
TO Water Main/Service Line /0 ~- To Stream, Pond, Lake, or Major Dmainage
co=se Z_~ o ~J ~
Receipt %
Date Paid:
Amount:
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Stzata
oate talled / %?
Width of Field / ~ ~
Length of Field ~
Depth of Field~/
Gravel Bed Thickness
Depression over Field (~"~ Dete of Last Adequacy Test
Results of Last Adequacy Test ~-~(~-~-~c ~-~.~
Separation Distance f~cm A~sC~ption Field:
To Water-Supply Well /~3E) ~ To P~operty Line /~)
To Building Foundation /~ ¢ To Existing or' Abandoned System cn
Lot /~D~'~ ; On Adjoining Lots .~c~
To Water Main/Service Line . /d~' ~-' To Cutbank(if present)
To Stream/Pond/Lake/or Major D~ainage Course //&/~Q
To D~iveway, Pa~king A~ea, c~ VehiCle Stc~a~e A~ea ~
Cc~m~nts /u~O ~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
~ ~ ~k/ Vent (Y/N)
Pumping Cycles ~ing Adequacy Test,
~ets MOA
** Check Permitted Bedroom Rating Against HAA Request
certify that I have checked, verified, c~ oonfcz~med to all MOA . ~.H~A Guidelines in effect
on the date of this inspection.
Signed
KB1/d5/s
[Pa~ 2 of 2]
[,1~..; Rebert A, She~r ? .':. ,?'
~n:'e No. 1457-E ; ,~:
2-15-84
/HEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER
5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
I,D, NO.
Water System Name ·
Mailing~.~Address
City State
1- 1,
Day Year
(*) See h on back
Phone No.
Zip Code
SAMPLE TYPE:
--~'Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
! [] Treated Water
d~.Untreated Water
SAMPLE
NO.
1
2
3
4
5
LOCATION
J
l 1
I
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[:~'~Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results. Please send new
sample via special delivery mail.
Date Received -. '~ '-' / ;" ' ~ "-'-
Time Received , , ~ /?
Analytical Method:
[] Fermentation Tube
'E~ ~lembrane Filter
Lab Ref': No. Result* Analyst
I I FTq
I r-Tq
I FTq
*No Of colomes/100 mi or NO of Positive portions
06-1220 (b)
Rev. 1983
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
..,BEFORE
COLLECTING SAMPLE
Membrane Filter:. Direct Count
Verification: LTB
Final Membrane Fl~/ttel~ Res, airs
,__~' ,!. /'~ / / .
Reported By .' ~':. '~,,'
Coilformll00ml
BGB
Collformll00ml
Date__' :T ~ /'/:.. ' "- f '~
Time: ,/' "r--c: ': ' '; a.m.
TNTC = Too Numerous To Count
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
1. GENERAL INFORMATION
Complete'legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Lot 9A. Amber S/D
Location (site address or directions)
17031
Foothill Road
Property owner-' Shawn FloriO Day phone 257-5000
l~Maili,gaddress 1..702 Aleutian. Anchorage.AK 99508
Lending agency
:,Mailin. g address
A~ent
Address
Day phone.
Day phone
Unlessothe~iserequested, HAA willbeheld~rpickup.
NUMBEROFBEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well
XXX
Community well
Public water
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public Sewer
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. . ..
XXX
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-O25(Re¥.1/91) Front MOA#21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
!nvestigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm S & $ ENGINEERING Phone ~' q b/ - 3->3 7 q
17034 Eagle River Loop Road No. 2~
Address r.~l~, River, Alaska cj9577
Engineer's signature ¢'~/~/ ~.~ ~¢7,~ Date //~_~'/eo
DHHS SIGNATURE
/~ Approved for 3
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with th-e following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasem of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineers work.
RECEIVED
Municipality of Anchorage dAN 2.8
DEPARTMENT OF HEALTH & HUMAN SERVIG~$¢m^u~,o~ ^NC~O
Environmental Services Division ~IVIRONMENTALSERVICESD
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
Health Authority Approval Checklist
A. WELL DATA
Well type
Log present (Y/N) y~
Date of test
Static water level
Well production
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to z~..O t 'f--
Casing height (above ground). ! '/-
Wires properly protected ~,~/N) y~:-S
FROM WELL LOG AT INSPECTION
~0 g.p.m. ~. I~
g.p.m.
WATER SAMPLE RESULTS:
Coliform
Date of sample:
! !
B. SEPTIC/HOLDING TANK DATA
Nitrate / '~ ~ Other bacteria
Collected by:
Date /O00 Number of Corn artments ~ Cleanouts Y,
installed //~)/~Z,~ Tank size p .__ ~
Foundation cleanout (Y/N) //V5 t'~ ~- Depression (Y/~) /V ('g High water alarm (Y/N)
Date of Pumping' ,/ /.,/ ~]/~ Pumper
C. ABSORPTION FIELD DATA
Date installed J O/~'.~ Soil rating ,g.p.d.lft~ ~ ~-/~'/~ System type K'/'/~
Length /z:~/ Width /"~' / Gravel thickness below pipe ~' /E"~ Totaldepth
Effective absorption area ~Z~ ~ Monitoring Tubepresen,~,),~-~ Depression over field (Y~
Date of adequacy test ,/,~/O(J Results(Pass/Fail) ~-~5~ For ~ '~'-~::::~./~, bedrooms
Fluid depth in absorption ne~d before test (in.); / ~ ~mmediately a,er~gal, water added (in.):
Fluid depth 4 ~, ~d~ g.p.d.
(~ Minutes later: ~ ~ Absorption rate =
Peroxide treatment (past 12 months) (Y/N) ~ ~W If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
Size in gallons
¢,4~/"'Pump on" level at*
*Datum
E. SEPARATION DISTANCES
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot /~ ')'-
Absorption field on lot
Public sewer main ~'-/,/~
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation /O/-'/'- Property line ~' /"/'- Absorption field
/
Water main/service line ~-~'- ../L Sudace water/drainage /O(.) ~,L Wells on adjacent lots
/(2o
/o0 /
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO;
Property line r/O/.'/-
Surface water r/(~O
Curtain drain ,7x,/O N'~-
Building foundation. /~ /'/-- Water main/service line ,//~ /C-
Driveway, parking/vehicle storage area /(~ /-'/-
,~A/C?-'U/'~/ Wells on adjacent lots ./'~7'~) /''/-
F. ENGINEER'S CERTIFICATION
I certify that I have determined ~
in conformance with MC)A H. AA~guidelines in, effect on this
Signature '~,/~/~ ',"~/~¢'~
Engineer's Name //~'~ ¢"z-;'~ ~- ~
Date } /~¢/00
date.
HAAFee $ ~ 0'7~.
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
CT&E Environmental Services Inc.
Laboratory Divi~n
PUBLIC WATER SYSTEM I.D.
pRIVAT£ WATER SYSTEM
200 W. pouer Drive
Tel: (907! 562.2343
)dp_king Water Analysis Report fo/' Total Coliform Bacteria ^'~°'"°'
A~sJs shows ~hts W~ SAMPLE
~ ~Sansfac~
Q Unsausf~
SAMPLE DATE: [~
Month
SAMPLE TYPE:
~ Re,tine
o Repeat Sample (for reuflne sampW
with lab rtl, no. -)
o Special
SAMPLE LOCATION
C
Day Veal'
~-/ IJn~d Water
Collm~
l~y
Sample ov~ 30 houri old, re~ult~ may
be umflisble
Snn~le mo I~g in ~g s~le
~ot ~ ov~ 48 hou~ old ~ ex.man
new ~le ~a ~al ~liv~ mad.
Analysis i~gnn
~,._bl~l~_~_r_. o f ce lonies/100 mL
10008G5
~"~c Fil~r
o IviWO4VlUG
Analyst
Jun
Faxt~
BAC~RIOLOGICAL WA1~R ANAL¥SI~ RECORD
COLIFI~M__
_ ColifOrm/tOO
Mm~b~ of m~ 885 Group i~c~O~ G~h~malo aa Sm.'ve¢le ncc) ~
FLORIDA. ILLJNOlS. MARYLAND. MICHIGAN, MISSO~RI. NEW JERSEY. OHIO. wEST ViRGINLA
O~-ZS-gO 19:~8
FROM-CTE ENVIRONMENI'AL
5~15301 T-dO? P.OZ?O~ F-g00
CT&E Environmental Services Inc.
Laboratory Division ~'
Laboratory Analysis Report
CT&E Ref.#
Client Name
Project Name/g
Client Sample ID
Matrix
Ordered By
PWSID
1000265001
S & $ Engiueering
LgA; Amber $/D
LgA; Amber S/D
Drinking Water
0
Sample Remarks:
Client
Printed Date/Time 01/25/~000 16:00
Collected Date/Yime 01/20/2000 15:30
Received Date/Time 01/~0/2000 17:05
Technical Director Stephen C.
A[Lo~abte Pr~o AnaLysiS
Limits Dace Date Inlt
UATER$ DEPT
Nirrate-N
1.80 0.500 mg/L EPA 300.0
(<10) 01/20/00 01/20/00 SCL
MICRO LAB
Total CoLiform
cot/lOOmL S~18 92228
01120/00 JOT
200 W. Potter Drive, Anchorage, AK 99518-1605 -- Tel: (907) 562-2343
:3180 Peger Road. Fairbanks, AK 99709~5471 -- Tel: [907l 474-8656 Fax: (907) 474-9685
ENVIRONMENTAL FACtLfflES IN ALASKA, CALIFORNIA. FLORIDA. ILUNOIS. MARYLAND. MICHIGAN. MISSOURI, NEW JERSey. OHIO. wEST vIRGINIA
ADDRESS _/70
LEGAL DESCRIFI'IOhL
DATE - Started
PE~IT NUMBER
STATIC LEVEL OF WATER Fi'.
DRAW DOWN FT. __
GALS, PER HR /~ 00
KIND OF CASING ~ zx
KIND OF FORMATION:
F,om~L~_F,. to ~ ,~,. ~ cdc/L
F, om~ ~,.,o t~ ' "" --
n.~_~.~-' · ~o~
From .... Ft. to. ._Ft.__.
From ~Ft. to~Ft ....
From----FI. to Ft.~
F[om .... Ft. to~Ft.~
From--- Ft. lO----..--Ft.~
From Fl, to_ .Ft.~
From~__,Ft. to___Ft ..... · ':
From .... FI, to Ft.~-
.~. From__
._ From
_ From
__ From
._ From,
From
From
to Ft.
to
to
to
Io__
to__~Ft.
to Ft.
Ft. lo~Ft,
.FI. to--Fl,-
Fl, tO
Ft. Zo .Ft,
Ft, lo~ Ft.
F;.[o Ft. __
FI, to .__Ft.__
.FI. to
MISCL. INFORMATION:
S NAMF ~ ~
DRILLER' - ....
I'lHbdl~; HUI'I~W Ul~Lll'lllEU
TUg 01:i4 P~
Jan. 19 2000 12:I9P1'1 Pi.
F, d~